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Full text of "Navy Department BUMED News Letter Vol. 5, No. 9, April 27, 1945"

NavMed 369 RESTRICTED 




Editor - Lt. Samuel Nesbitt, (MC) t U.S.N.R. 



Vol. 5 Friday, April 27, 1945 No. 9 



TABLE OF CONTENTS 



Japanese B Encephalitis.... 1 

Flashburn Cream: Trial in Combat ...,2 

Immunity in Mumps: Detection 3 

Schistosomiasis: Occurrence 3 

Schistosomiasis: Diagnosis 4 

Research in Shock 5 

Burns: Toxemia in 8 

Burns and Liver Function 8 

Actinomycosis: Chemotherapy 9 

Penicillin in Meningitis 9 

Penicillin in Pneumonia 10 



Form Letters: 



Mild Primary Atypical Pneumonia .. 10 



Pleural Fluid 12 

Anticoagulant Therapy 13 

Novocain Injection Therapy 16 

Survival in Cold Water 17 

Rupture of the Spleen 18 

Peptic Ulcer: Vagus Section in 19 

Peptic Ulcer: Enter ogastr one........ 20 

Coccidioidin Skin Test 20 

Erratum 21 

Bath Dermatitis 22 



Navy Nurse Corps, Marriage of Officers BuMed... 23 

Communicable Disease Report, Discontinuation of BuMed.. '. 23 

Alnav 54 - Detachment of Officers SecNav ......... 27 

Photofluorographic Chest Examinations BuMed 27 

Official Status of Red Cross Personnel. . SecNav 27 

Navy Nurse Corps, Discharges BuMed 30 



****** 



Tapanese B Encephalitis: Since the publication of a review on Japanese B 
encephalitis in the Burned News Letter of February 16, 1945, it has been learned 
that Naval Medical Research Unit #2 is desirous of securing acute -phase and 



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Burned News Letter, Vol. 5, No. 9 RESTRICTED 

convalescent sera for diagnostic studies from suspected cases of this disease 
arising in Pacific areas west of the Marianas Islands. It must be emphasized 
that it is not possible for the unit to give immediate answers to diagnostic 
problems due to the involved technic required, since at best, the procedure for 
laboratory diagnosis of Japanese B encephalitis is experimental. In addition to 
sterile sera (10 c.c. samples) taken during acute and convalescent phases of the 
illness, this unit is desirous of securing autopsy specimens of the brain and 
spinal cord (bacteriologically sterile and in 50 per cent CP glycerine) of fatali- 
ties occurring in the Western Pacific which are suspected of being due to en- 
cephalitis. All specimens should be sent via air to Naval Medical Research 
Unit #2, c/o Fleet Post Office, San Francisco, California. 

Medical officers in the Pacific are urged to notify immediately Naval Medi- 
cal Research Unit #2 and the Bureau of Medicine and Surgery of all outbreaks 
of disease suspected of being encephalitis. NAMRU #2 is prepared to send spe- 
cial personnel to the locale of such outbreaks to conduct much needed investiga- 
tions on the nature of this disease. (Prof. Div., BuMed - F. A. Butler) 

Cream for the Prevention of Flashburn Found Effective in Battle Trial: 
The protective effect of flashburn cream in combat has been proved, according 
to an enthusiastic report recently received from the Pacific area. On a large 
ship in naval combat 75 per cent protection was afforded by the cream to those 
who were subjected to flash. 

In one case cited in the report a man was only 30 feet from a large bomb 
which exploded. His face, covered by flashburn cream, received only first de- 
gree burns. His unprotected legs received second degree burns where his trou- 
sers were blown off. Another man had cream on his face but not on his neck. 
He received first degree burns on his neck but none on his face. These instances 
and others give evidence of the relative damage to unprotected skin, skin covered 
by clothing, and skin covered by flashburn cream. They confirm experimental 
data which indicated that this cream, when properly applied, was very effective. 

The report states that the cream was found to be more comfortable and prac- 
ticable for gunners and personnel in hot spaces than was flash clothing, but it 
recommends that the use of the cream be mandatory for all hands, regardless of 
battle station. 

As a result of the experiences in this battle, it is recommended that the 
cream not be applied until just prior to action. Application was foundtobe more 
effective if each man applied the cream to another rather than to himself. 



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Burned News Letter, Vol. 5, No. 9 RESTRICTED 

. ■. ■ 



The fact that this cream has been shown to be acceptable to personnel and 
effective in use should encourage all personnel to take advantage of this means 
of decreasing the incidence of flashburn. 

The Detection of Immunity in Mumps: In the complement-fixation test, a 
laboratory method of diagnosis has been made available which should be of 
particular assistance in situations where infection with the virus of mumps 
is suspected, but where the diagnosis cannot be made solely on the basis of 
clinical signs. Acute, aseptic meningoencephalitis without involvement of the 
salivary glands, is the most important of these conditions. 

Both the complement fixation test and a skin test for dermal hypersensi- 
tivity, although their accuracy is not absolute, afford means of revealing which 
of the individuals in a population are immune or potentially susceptible. Since 
the skin test is by far the simplest procedure, it is probably the method of 
choice for this purpose, especially if further studies lead to a better under- 
standing of its limitations. 

Satisfactory ways of inducing either active or passive immunity have not 
as yet been devised. Experimental data on the effect of prophylactic vaccina- 
tion with formolized suspensions of monkey virus do, however, holdmuchprom- 
ise that the problem of active immunization can be solved". (OEMcmr-139, Cohn 
and Enders - Harvard Medical School. To be published. CMR Bulletin #27) 

****** 



Schistosomiasis: Occurrence in Military Personnel : Ina discussion of 
schistosomiasis appearing in the Burned News Letter of January 19, 1945, it was 
pointed out that this disease was known to be endemic in Leyte, Mindoro and. 
Mindanao Islands of the Philippine group as well as in many other areas of the 
Western Pacific. Reports from Leyte reveal that over three hundred cases of 
■schistosomiasis due to.S_. Japonicum have been diagnosed among American 
troops during the present operations, and it is suspected that there are several 
thousand other cases. The infestation has been confined to troops who, by the 
nature of their duties, were required to wade through canals, ditches and streams 
The disease has been severe, and several deaths have been reported. Fuadin 
and tartar emetic were employed in therapy and generally were effective when 
used early and adequately. 

It is expected that this disease will occur among our personnel in almost 
all new areas of operation in the Pacific, and it is to be suspected as a possible 
cause in all unexplained cases of diarrhea, urticaria, pulmonary symptoms or 



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Burned News Letter, Vol. 5, No. 9 RESTRICTED 



fever. Laboratory technicians should be instructed to examine carefully stool 
specimens for the characteristic ova. Therapy should be prompt and thorough. 
(Prof. Div., BuMed - F. A.- Butler) 

T he Laboratory Diagnosis of Oriental Schistosomiasis: The laboratory 
diagnosis of Schistosoma japonicum infestation is based on the demonstration 
of eggs of the parasite in fecal specimens. If the infestation is heavy, and large 
numbers of eggs are being shed into the fecal stream, they usually can be 
found in ordinary wet preparations, particularly if these are made from a bloody 
portion of the stool. If, however, the infestation is- light and schistosomiasis is 
strongly suspected on a clinical basis, other methods for detecting eggs must 
be tried. 

A comparison of the various procedures recommended for this purpose 
has recently been completed at the Naval Medical Research Institute. The ' 'acid- 
ether" method was the easiest of the concentration methods to perform, and It 
gave the most consistently reliable results. The following procedure is a recent 
modification made by Dammin and Weller, of the original method of Telleman, 
for their survey on S. mansoni in Puerto Rico: 

"Approximately one gram of fecal material is thoroughly emulsifiedin5 c.c. 
of hydrochloric acid (40 c.c. concentrated HC1 diluted to 100 c.c.) in a test tube. 
The material is filtered into a 15 c.c. centrifuge tube through two layers of moist 
gauze stretched over the top of a 50 mm. glass funnel. An equal quantity of ether 
is added, and the tube is stoppered with a gloved finger and shaken thoroughly. 
It is then centrifuged for one minute at 1 500 r. p.m. Upon removal from the centri- 
fuge the debris floating at the acid-ether junction is loosened by ringing with a 
clean applicator, and the acid and ether layers are rapidly poured off and dis- 
carded. The same applicator is then used to stir the sediment in the few drops 
of fluid remaining, the sediment is decanted on to a slide, and a cover-slip 
applied." 

The following results were obtained in a typical experiment in which the 
tests were done on thoroughly mixed fecal samples obtained from naturally in- 
fected dogs returned to this country from Leyte, Philippine Islands: 

METHOD £. TAPONICUM EGGS 

(No. per cover-slip p re paration) 



Ordinary wet smear . 9 

Sedimentation 29 

Acid- ether 158 

Zinc sulphate flotation 0 



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It will be noted that the zinc sulphate method failed to concentrate S. 
japonicum eggs. In an experiment designed to determine the reason for this 
failure, it was found that the eggs were all in the sediment. 

The acid-ether method does not produce noticeable distortion of the eggs 
which are easily recognizable. (D. R. Mathieson, Nav. Med. Res. Inst., 
Bethesda, Md.) 

* * * * * * 

Shock: Since the outbreak of the war, research on shock has been acceler- 
ated. Such studies have involved as many scientists and have entailed as much 
"expense as has any other phase of military medical research. A mass of data 
has accumulated and,unless this is properly evaluated and efforts are directed 
along those lines which appear of greatest promise in the light of present knowl- 
edge, sound theory and rationale may not evolve. It seems reasonable to select 
such methods of attack on the shock problem as have shown most promise and 
to concentrate future efforts accordingly. These methods have not been as varied 
as one might imagine. 

Various methods of producing the shock syndrome experimentally have been 
studied, so that a direct comparison of methods of treatment might be made. This 
approach is important, since many descriptions of shock in the literature 
are o^f a condition which is not at all shock as seen by the military surgeon. 
This confusion was recognized in the early days of the war, but the same situa- 
tion apparently still exists. Methods of producing shock have included traumatic 
crushing, agitation in various types of scarifiers, the use of tourniquets, drugs 
(histamine, depressor substances, toxins), hemorrhage, hot water burns, and 
controlled impact (pendulum, falling body). The latter method shows much prom- 
ise, since by its use the amount of energy delivered to the tissues is known and 
follows ballistic laws. In war, trauma is caused by missile impact and it is 
therefore logical to select a method most nearly simulating a battle injury. 

Among studies pertaining to the treatment of shock, replacement therapy, 
including the use of blood and blood substitutes, has been preeminent. In re- 
placement therapy there can be no disagreement with the fact that whole, human 
blood is the fluid of choice. To this extent the problem of replacement was solved 
when the use of blood transfusion first came into general use. However, the war 
has presented the necessity for finding a blood substitute. Human plasma is not 
an ideal solution for use in increasing the circulating blood volume, since the 
ideal substance would be one which could be made synthetically, could be stand- 
ardized and would not deteriorate. Of the substances tested during the war , 
sodium chloride or lactate administered by mouth to increase blood volume, and 
gelatine as a blood substitute have met with the most general success and would 
appear to be those most worthy of future study. 

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The use in shock of cortico-adrenal extracts, cortical' steroids and pres- 
sor substances has been studied. Cortico-adrenal preparations have been 
investigated because of their effect on capillary permeability, and electrolyte 
and carbohydrate metabolism. Since it is now denied that there is general 
plasma leakage and the present theory considers fluid loss to involve only the 
areas of injury, the outlook does not appear too bright for these preparations. 
However, those workers who hold that potassium intoxication is involved in 
shock, as in adrenal insufficiency, advance arguments for employing these ex- 
tracts and steroids in the treatment of shock. These reports are so volumi- 
nous that a final evaluation of these substances is necessary. Pressor sub- 
stances are all rather transitory in action. They are contraindicated when 
shock is due to low blood volume and bleeding is present, when replace- 
ment therapy obviously is the proper one. It is doubtful that either drugs or 
organotherapy will lead us to a clearer fundamental knowledge of shock. The 
most fundamental work obviously deals with cellular metabolism, specifically 
that of the anoxic cell. Attempts have been made to study the effects of shock 
on cellular physiology, but thus far little of practical value has been found. 
More promising have been the studies of general metabolism involving elec- 
trolytes, uric acid, non-protein nitrogen, phosphorus, carbohydrate and pro- 
tein, hi shock, the loss of sodium to the cells and the increase in extracellular 
potassium with toxic effect have been fairly well established. Long's work has 
shown that shock tissues are anoxic tissues and that, anoxia may so alter general 
and cellular metabolism that restoration of normal conditions becomes impossible. 

Capillary permeability has been studied by means of tagged proteins, mi- 
croscopic studies on living animals, blood volume and hemoconcentration studies. 
From such work has come the rather revolutionary concept that increased capil- 
lary permeability is not of a generalized nature but is restricted to the injured 
area. The "white hemorrhage" the o ry is not now believed tenable. 
However, a fundamental knowledge of altered capillary permeability is so neces- 
sary to a theory of shock that such studies should be pursued and the whole 
question of capillary leakage cleared up. 

The question as to whether toxic factors, including depressor substances 
and muscle "shock factors", exist in shock must be answered. The data in 
the literature is highly conflicting on this subject and the best evidence indicates 
the absence of such factors. The toxic theory of shock, however, has been en- 
trenched in physiological thought so long that the existence of toxic substances 
in shock is still debatable. Such a substance originating in crushed muscle has 
been identified as adenosinetriphosphate. On the other hand, cross -transfusion 
experiments have been entirely negative. 

The. role of the nervous system in shock provides a large field for investi- 
gation. Early reports indicated that anesthetics, such as intravenous pentothal 
or other barbiturates, were the ones of choice in surgery upon shocked patients. 



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This is logical from what is known of the role of the central nervous system in 
shock. More recently, opinion appears to be forming that such drugs are contra- 
indicated. According to this school of thought, cellular metabolism is already 
depressed in shock and the use of any anesthetic is detrimental. ■ This problem 
should be cleared up, since it bears directly upon the fundamental genesis of 
the shock state. 

General reports (particularly from Russia) have advocated freezing tech- 
nics in surgery. In amputations this method has been quite generally acclaimed, 
and the "frozen" surgical field has been described as a "bloodless, shockless 
field". Since the freezing technic most certainly acts on the nervous system, 
it should be considered in relation to a basic study on the role of the central 
nervous system in shock. 

Russian observers have reported, for some time, the beneficial effects of 
nerve block. Experiments in this country, in which the severing of nerves is 
said to have no effect upon the shock syndrome, may be largely disregarded, 
since such cutting sets up "currents of injury" within the nerve and, if the 
nervous component of shock be large, such cutting should tend rather to pro- 
duce the state than to alleviate it. The effect of true "nerve block" - the preven- 
tion of the passage of afferent sensory impulses past the point of block - must 
be evaluated as a shock preventive in any comprehensive study of shock etiology. 

Wound ballisticians have noticed that missiles entering an animal in a non- 
vital area (but one which contains major blood vessels) may result in instan- 
taneous death. This is believed to be due to hydraulic, transmitted shock. Thus, 
on missile impact, energy is transmitted through the tissues, and particularly 
through the blood vessels, to the vital centers of the brain. While this form of 
"shock" is not intimately associated with the fundamental shock problem dis- 
cussed, it might well be investigated by persons conversant with the theory and 
syndrome of traumatic shock. 

Although many other phases of the shock problem have been investigated, it 
is felt that the above lines of investigation offer the most promise, when evalu- 
ated in the light of past reports. Research programs have been, in general, too 
catholic, so that we find individual laboratories changing their plans of attack 
again and again, with resultant dissipation of energies over a multitude of ap- 
proaches to their goal. As a result we find the fundamental problems still un- 
answered. Post-war research should be so designed as to eliminate false con- 
ceptions and bring us step by step closer to an understanding of the fundamental 
etiology of "shock". (Research Div., BuMed - E. L. Corey) 

* * * * * * 



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Burned News Letter, Vol. 5, No. 9 



RESTRICTED 



Toxemia Syndrome Following Burns : In the course of a clinical study of 
burn toxemia, Walker and Shenkin observed six patients who died of sudden re- 
spiratory arrest at a time when hepatic and renal manifestations of burn toxemia 
were subsiding. During the period of toxemia these patients showed varying de- 
grees of disturbance of the central nervous system. Autopsy findings in every 
case -substantiated the impression that there were organic changes in the brain, 
especially in the cortex and hypothalamus. 

Since methods of treating burn shock have improved, a number of severely 
burned patients survive the first 48 hours only to succumb during the next few 
days to what Wilson and his collaborators have termed "toxemia". There may 
be greater or lesser degree of renal damage in these patients, as evidenced by 
oliguria and azotemia, as well as some hepatic injury. 

In the experience of these investigators there was associated with the evi- 
dences of visceral damage a definite degree of involvement of the central ner- 
vous system. The patients showed varying degrees of disorientation and drowsi- 
ness leading to stupor. Occasional patients became maniacal or were subject to 
hallucinations, and all showed myoclonus, muscular twitching and increased re- 
sistance to passive motion. These signs persisted for several days, and then 
cleared along with the other signs of toxemia in those patients who recovered. In the 
fatal cases death was often sudden; signs of renal and hepatic damage had begun 
to lessen and the patients had begun to improve clinically, when respiratory fail- 
ure occurred. Some severely burned patients showed Cheyne -Stokes respira- 
tion or irregular periods of apnea prior to sudden respiratory failure. These 
deaths were believed to be due to damage to the central nervous system, with 
failure of the medullary centers, the result of compression, edema and cellular 
lesions. 

Gross examination of the brains revealed evidence of increased intracranial 
pressure with herniation of the cerebellar tonsils through the foramen magnum 
compressing the medulla. Histological examination showed severe interstitial 
edema and changes in the ganglion cell which were found to be most marked in 
the hypothalamus. It is suggested that the central nervous system changes are 
an important factor in the explanation of the sudden deaths occurring in the 
toxemic phase of burns. (Ann. Surg., March '45) 

Effect of . Lo c al Treatment of Burns on Liver Function: Our knowledge of 
the effect of local treatment of burns on liver function has been obtained in the 
past either by animal experimentation or by study of the pathological changes 
found in fatal cases of burns at autopsy. Saltonstall et al have presented a study 
which has been concerned primarily with the functional changes in the livers 
of burned patients as determined by various tests, including the van den Bergh, 



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Burned News Letter, Vol. 5, No. 9 RESTRICTED 



the retention of bromsulphalein, the excretion of hippuric acid and the floccula- 
tion of cephalin-cholesterol emulsions. They state that emphasis on the hepato- 
toxic properties of tannic acid came at a time when the visceral changes follow- 
ing burns were becoming of increasing importance, probably as the result of 
improvement in the treatment of shock. 

They conclude that the use of tannic acid in treating burns impairs liver 
function and that other tanning methods also impair liver function, although to 
a lesser extent. Impairment of liver function also occurs in patients treated 
with petrolatum gauze and pressure dressings, but it is usually slight. The 
abandonment of the use of tannic acid in the local treatment of burns has not 
resulted in a decrease in mortality in their series. (Ann. Surg., March '45) 

*Jc ifc 4e i 
T" 'T* ' i * 

Sulfonamides and Penicillin in the Treatment of Actinomycosis; Sixteen 
cases of actinomycosis treated with sulfonamides or penicillin have been re- 
ported. These cases included 3 of the pulmonary type, 2 of the abdominal type 
and 11 of the cervicofacial type. Of the 16 cases treated, 7 may be considered 
cured, and 7 arrested, while 2 have died. 

In vitro tests have corroborated the clinical impression that there are vary 
ing degrees of susceptibility of actinomyces to sulfadiazine and penicillin and 
that sulfadiazine appears to be slightly more effective in certain instances. 

The results in these cases indicate that both penicillin and the sulfonamide 
are highly effective drugs in the treatment of actinomycosis. (Dobson and Cutting 
Stanford Univ. To be published. CMR Bulletin #29) 

+ jjt + + j): % 

Penicillin in the Treatment of Acute Meningitis: Penicillin is often 
effective in pneumococcal, meningococcal, streptococcal and staphy- 
lococcal meningitis after sulfonamide therapy has failed to produce the desired 
response . In pneumococcal meningitis , the presence of subcranial foci and 
old age decrease the chance for survival. The superiority of penicillin 
over other forms of chemotherapy is most clearly demonstrated in staphy- 
lococcal meningitis. 

Although penicillin administered by the systemic route alone may have a 
curative effect in selected cases, it seems preferable to supplement systemic 
administration with intrathecal injections of the drug by the cisternal route. 
Intrathecal penicillin therapy does not appear harmful. 

It is likely that best results in coccal meningitis will be obtained through 
the use of a combination of penicillin and sulfonamides systemically together 



Burned News Letter, Vol. 5, No. 9 RESTRICTED 



with penicillin intrathecally. (OEMcmr-56. Ms for publication - Rhoads et al - 
Univ. of Pa. - CMR Bulletin #31) 

Penicillin in Pneumonia: The routine reporting of penicillin treatment to 
the Bureau of Medicine and Surgery has been discontinued for all diseases ex- 
cept syphilis. Exclusive of venereal disease, more than 8,000 reports of such 
treatment were received and studied by the Bureau. In general, the results 
were consistent with those obtained elsewhere and reported so voluminously 
in recent medical literature. The reports from naval medical officers dis- 
close one fact which has not as yet been emphasized - that in pneumonia the 
mortality and complications are reduced if penicillin is used in preference to 
sulfadiazine. 

In the Naval Medical Bulletin of March 1 945 , an analysis of 589 cases of lobar 
pneumonia and bronchopneumonia treated with penicillin was reported. The aver- 
age dose was minimal, and uncomplicated recovery of the patient was more consist- 
ent when penicillin was used immediately. When penicillin treatment was de- 
layed by the initial use of a sulfonamide, larger doses were needed and more 
failures were encountered. Twenty-eight cases of uncomplicated lobar pneu- 
monia and 12 cases of bronchopneumonia were treated immediately with peni- 
cillin; the average total dosage in the cases of lobar pneumonia was 533,000 
Oxford units, and in the cases of bronchopneumonia was 409,000 units. All 40 
cases recovered without complication. In the treatment of 272 patients with 
uncomplicated pneumonia, a sulfonamide had been used initially which was sup- 
planted by penicillin because of failure of the disease to respond to the sulfona- 
mide. Penicillin produced a successful response in 256 (94 per cent) of these. 
It cannot be estimated how the 16 failures (with 3 deaths) would have responded 
had penicillin been used at the onset of illness, but the general superiority of 
penicillin over sulfonamides seems apparent. 

The average dose of penicillin for pneumonia is 100,000 Oxford units daily. 
Not only is it the drug of choice in pneumococcal, staphylococcal and strepto- 
coccal pneumonia, but also evidence is accumulating that its trial is justified 
in most cases of primary atypical pneumonia. (Prof. Div., BuMed - A. G. Lueck) 

3|e $ sjc + + + 

The Problem of Diagnosis of Primary Atypical Pneumonia in Mild Gases : 
Tumulty has made an analysis of 93 cases of primary atypical pneumonia which 
occurred sporadically in a large number of units in a tropical area. The disease 
was characterized by its mildness, and there were no complications or deaths. 
Great difficulty was encountered in early diagnosis because of the complete 
absence, in many of the cases, of historical data or physical findings which 



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would indicate pulmonary pathology. The disease was frequently confused 
with one of the common upper respiratory infections, with dengue or with 
malaria. In this series the diagnosis of primary atypical pneumonia was 
made on admission in only 32 per cent of the cases, and was considered as a 
possibility In an additional 16 per cent. Often a clinical differential diagnosis 
was impossible, and an early diagnosis depended upon the result of roentgeno- 
graph^ examination made when the possibility of primary atypical pneumonia 
was considered. 

In general, the febrile period was of brief duration. Twelve per cent of 
the cases were afebrile throughout their hospital course, 61 per cent were 
afebrile after four days and 95 per cent by the end of ten days; a few patients, 
however, continued to run a low grade fever for from 18 to 21 days. In two 
cases the diagnosis of pulmonary tuberculosis was considered seriously. In 
one instance, roentgenograp hie examination revealed infiltration at the left 
apex of the lung which was suggestive of tuberculosis. In the other, there was 
widespread pneumonia i n a n acutely and chronically ill patient whose history 
and physical examination strongly suggested tuberculosis. A small group of 
patients had no fever and complained of little more than general malaise and 
easy fatigue. Physical examination of these patients was essentially negative, 
and except for roentgenographic findings they might have been considered 
malingerers. 

Four commonly recognized types of changes were seen on roentgeno- 
graphic examination: (.1) patchy areas of infiltration, the density varying from 
snowflake to cotton ball appearance; (2) homogenous areas of infiltration, possi- 
bly the result of confluence of patches, judging from the appearance of the edges 
of these lesions; (3) areas where the infiltration appeared chiefly in strands, 
beginning at or near the periphery of the lung fields and converging toward the 
hilum; (4) a marked increase in the prominence of one root shadow without sig- 
nificant parenchymal Involvement occasionally was the only alteration observed. 
The first three of these types of change were invariably limited to a segment of 
one or more of the lobes and never involved an entire lobe. 

In some cases any one of the above four changes could be seen; others ex- 
hibited a combination of two or three types, and in one case all four changes 
were observed. The strand-like type of Infiltration has been considered by some 
to represent the very earliest appearance of the pneumonia, while others have 
come to regard it as a clearing phase. In this series it was encountered about 
as frequently during the first two to four days of the disease as it was after 
from 12 to 14 days of illness. The pleural involvement which occurred in three 
cases, as evidenced by roentgenographic examination, was always interlobar, never 
produced physical signs and cleared without residue. Two patients with clinical 
signs of pleuritis showed no radiologic evidence of such involvement. Nothing 
of prognostic significance could be discovered except that those patients with 



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the most extensive involvement of the lung were, in general, the most severely 
ill. Marked involvement of the lung root was not associated with severe or pro- 
longed cough as has been suggested in the past. 

The roentgenographic changes observed in some cases could be confused 
with those of bronchopneumonia, or with those of an early or resolving lobar 
pneumonia. Serial films were necessary for differentiation. The changes would 
not be confused with the picture of full-blown lobar pneumonia. In two cases 
in which the roentgenographic picture simulated tuberculosis to a remarkable 
degree, the correct diagnosis was established by the clinical course of the dis- 
ease, and by repeated roentgenographic examination. (Bull. Johns Hopkins Hosp., 
Nov. '44) 

* * 

Occasionally roentgenographic evidence of primary atypical pneumonia 
which otherwise would have been overlooked is found at the time of a routine ex- 
amination, such as an induction examination or an annual physical examination. 
Questioning may reveal that the individual has not been ill recently. He may 
have had^a cold or felt otherwise slightly or moderately ill at some time prior 
to the examination, he may not have been sufficiently ill to consult a physician, 
and he may or may not have been incapacitated temporarily. Such a situation 
presents a problem of considerable magnitude as to the differential diagnosis 
of pulmonary tuberculosis, particularly when the lesion is at the apex. D if - 
ferentiation can be made only by a careful clinical investigation and serial roent- 
genographic examinations over a long period of time. 

T 'F t'' *r *^ *¥■ . 

The Significance of Fluid in the Pleural Space: The presence of fluid in the 
pleural space has been described by a variety of terms, depending on the eti o - 
logic factors involved. The term "hydrothorax" is used to describe a condition 
in which the fluid is clear, serous and of low specific gravity. This fluid, which 
is a transudate, is the type found, for example, in association with congestive 
heart failure or nephritis with edema. When the fluid is the result of inflam- 
mation of the pleura, the condition is called "pleurisy with effusion". The fluid 
is an exudate, and its specific gravity exceeds 1.012. When a pleural effusion 
becomes infected, "empyema" is said to be present. The term "hemorrhagic 
pleural effusion" describes a condition in which the fluid contains a sufficient num- 
ber of red blood cells to produce a pink or red color . Approximately 5 ,000 to 6 ,000 
red blood cells per cubic millimeter are required to give the fluid a red tint. Changed 
hemoglobin usually imparts a brown or amber color to the fluid. If pure blood 
is present in the pleural space, the condition is called "hemothorax". If the 
fluid contains an excess of fat globules, the condition is called "chylothorax". 
Disturbances in lymphatic circulation cause chylous fluid. 



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The presence of fluid in the pleural space is almost always indicative of 
serious organic disease. Possibilities to be considered in differential diag- 
nosis include: carcinoma, congestive heart failure, lymphoblastoma, pneu- 
monia, tuberculosis, cirrhosis of the liver and nephritis. 

It is important to examine aspirated fluid carefully. The gross character- 
istics should be accurately recorded and the specific gravity and the number of 
cells should be determined. Bacteriological studies should be made routinely 
and, in addition, culture for the tubercle bacillus or inoculation of animals is 
frequently indicated. A careful search for neoplastic cells should be under- 
taken. If the presence of chylothorax is suspected, the fluid should be examined 
for fat. (Tinney and Olsen, Staff Meet. Mayo Clin., March 21, '45) 

Anticoagulant Therapy : Recent concepts of anticoagulant therapy includ- 
ing the use of dicumarol were discussed in the Burned News Letter of April 14, 
1944, and the effect of preparations of vitamin K activity on the prolonged pro- 
thrombin time resulting from the administration of dicumarol was mentioned 
in the Burned News Letter of June 23, 1944. Many investigations continue in this 
interesting and promising field as is evidenced by the increasing number of 
publications. 

Attempts are being made to prolong the action of heparin, which would elimi- 
nate one of its chief disadvantages. Loewe et al administered the drug in the 
Pitkin menstruum and found this mixture capable of prolonging the effect of 
heparin in rabbits. The effect of a single dose lasted from twenty-four to as long 
as seventy-two hours. In several animals heparinization was initiated with 50 mg. 
of heparin in this menstruum, and was maintained as required with 25 mg. doses. In 
this manner it was possible to continue adequate heparinization over a two- week 
period with a total dose of 100 mg. This result may be contrasted with the two- 
week requirement of 630 mg. of commercial heparin given subcutaneously in 
fractional daily doses of about 45 mg. Bryson has prolonged the anticoagulant 
action of heparin by suspending it in a beeswax- sesame oil mixture. After in- 
jection in dogs of from 100 to 150 mg. of heparin in from 0.5 to 1.5 c.c. of the 
beeswax mixture, the coagulation time of the blood was increased for periods 
which ranged from seventeen to seventy hours. In most instances the coagula- 
tion time during these periods was within satisfactory therapeutic limits. Judd 
has employed this method of administration in five patients. Two hundred milli- 
grams of heparin in 2 c.c. of the 10 per cent mixture of beeswax were injected 
intramuscularly in most of the patients. The injection was harmless, and pro- 
longation of the clotting time of the blood was produced in each case. The peak 
of the reaction curve was reached in twenty-four hours, at which point a plateau 
developed which was maintained for a period of from three to five days. This 
series is unfortunately too small to permit any definite conclusions. 



Burned News Letter, Vol. 5, No. 9 RESTRICTED 



The synergistic action of heparin and dicumarol was recently studied b y 
Walker and Rhoads, They reported that under controlled conditions the action 
of heparin was enhanced by dicumarol, when the prothrombin time was depressed 
to 20 or 30 per cent of normal, by the action of the latter drug. From one -half 
to one-third of the usual amount of heparin was needed to produce a given effect 
in the subjects treated with dicumarol. This effect is not unreasonable when 
one considers that dicumarol reduces prothrombin, and that the susceptibility 
to the action of heparin is related to the amounts of prothrombin and thrombin 
in circulation. From a clinical standpoint the importance of this observation is 
questioned, as the drugs are seldom used together except when quick anticoagu- 
lant action is desired, and under these circumstances for a few days only. 

Meyer and Spooner found that dicumarol was absorbed when administered 
rectally and produced effects similar to those resulting from oral or intra- 
venous administration of the drug. There was no change in the latent period 
by this method of administration. The drug was inserted either in an aqueous 
suspension or in a cocoa butter suppository. 

McCarter et al administered very large doses of dicumarol to dogs. The 
animals were killed. and the following outstanding morphological evidences of 
poisoning were noted: toxic lesions of the small blood vessels sufficient t o 
make hemorrhages almost inevitable, acute renal glomerular swelling and a 
toxic reaction in the lymphoid tissues. No necrosis of the liver was found, 
and there were no lesions consistent with hepatic degeneration. In six dogs 
receiving dicumarol in therapeutic levels of dosage, mild lymphoid tissue re- 
action was noted in one animal. Autopsies performed on five human beings 
with a variety of diseases, and who were receiving dicumarol at the time of 
death, revealed none of the toxic changes just described. In several instances 
a mild lymphoid reaction could be detected. 

Cahan described a patient who received 2,800 mg. of dicumarol in thirty- 
two days and who had hemorrhagic and purpuric manifestations. There were 
an associated prolongation of the bleeding time and a pronounced deficiency of • 
prothrombin without reduction in platelets, capillary fragility or abnormality 
in clot retraction. From the result of a needle-puncture tourniquet test Cahan 
concluded that dicumarol induces not only hypoprothrombinemia,but also an in- 
creased sensitivity of the vascular bed to trauma, 
j 

Lucia and Aggeler recommended vitamin K4 oxide as a means of treating 
dicumarol-induced hemorrhages. By the intravenous injection of 500 mg. of 
vitamin Kl oxide they were able to elevate the prothrombin concentration i n 
the blood of a man who had received large doses of dicumarol. The period be- 
tween the institution of treatment with vitamin E4 oxide and the cessation of the 
hemorrhagic phenomena was too long to make the method entirely satisfactory. 



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Burned News Letter, Vol. 5, No. 9 



RESTRICTED 



Morton et al have investigated the possible influence of vitamin K on 
thrombus formation in dogs. The radial and saphenous veins of the legs of 
52 dogs were traumatized mechanically by scarifying the intima with a hooked 
needle . The veins were removed at intervals of forty-eight and ninety-six hours 
afterward. Twenty-seven of the animals received a surplus of a synthetic 
preparation of vitamin K activity along with the regular diet for a week prior 
to the injury, and the remaining 25 served as controls. The results of deter- 
minations of prothrombin and clotting times as well as hematocrit determina- 
tions made at intervals on each animal demonstrated that the administration 
of synthetic vitamin K was without effect. The incidence of thrombosis after 
injury to the intima of the veins was not significantly increased by the coinci- 
dent administration of a synthetic preparation having vitamin K activity. 

Rabinovitch and Pines produced local clot formation in the veins of rabbits 
by a forcible pull on the vein followed by partial constriction at the site of in- 
jury. When heparin was administered, even in small doses,before injury of the 
vein and formation of a thrombus, it prevented the subsequent development of 
a local intravascular clot. It was not necessary to administer the anticoagu- 
lant continuously in order to obtain the desired effects of the drug. In a cer- 
tain number of animals, heparin proved effective in causing the solution or 
disappearance of a thrombus, but only when given during the early stages of 
clot formation. It had no effect when given after the clot had already organized. 

Shapiro et al administered dicumarol to 18 patients with hepatic disease 
and hypoprothrombinemia. The dose selected was 50 mg. which was considered 
to be one -half the minimal dose capable of prolonging the prothrombin time in 
normal persons. All of the patients with Laennec's cirrhosis who had marked 
or moderate prolongation of the diluted-plasma prothrombin time showed a 
definite response to the small dose of dicumarol. Of the six patients with slight- 
ly prolonged diluted-plasma prothrombin time, three showed further increase, 
while those with an initial normal prothrombin time did not respond to dicumarol. 
In those patients in which prolongation of the prothrombin time did occur, the 
time of the first detectable change was the same as in normal persons. 

Wasserman and Stats found that dicumarol produced a variable response 
in 71 adult patients when administered in the usual manner; a fixed dosage 
schedule could not be made. Of eight patients in whom hemorrhages developed, 
there was one death. This patient's prothrombin time was 7 per cent at the 
time of bleeding, which occurred at the site of an amputation and from the rec- 
tum. In four other cases transfusions of fresh blood did not arrest the hemor- 
rhagic tendency due to dicumarol. Several instances were reported in which 
embolism, thrombosis or progression of existing'venous thrombosis occurred 
despite a low blood prothrombin. The drug failed to produce symptomatic im- 
provement in ten cases of occlusive peripheral vascular disease during a three- 
month trial. These workers feel that dicumarol needs further trial before its 



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Burned News Letter, Vol. 5, No. 9 RESTRICTED 



effect can be determined in cases of peripheral venous thromboses and pulmo- 
'nary infarction. 

Evans has also emphasized the dangers and disadvantages of dicumarol, 
but in his opinion the obvious advantages far outweigh the dangers of this pre- 
ventive measure, although adequate laboratory studies must be made and proper 
precautions be observed. Fifty-six patients were treated with dicumarol alone, 
or with dicumarol combined with heparin. Of four deaths which occurred, two 
were ascribed directly to dicumarol poisoning and hemorrhage. Hemorrhagic 
phenomena were evident in eight cases (14 per cent). 

Evans reemphasized the principal precaution to be observed in adminis- 
tration of dicumarol, the determination of the morning prothrombin time be- 
fore ordering the daily maintenance dose. The combined use of heparin and 
dicumarol was considered safe only if the doses of heparin were controlled by 
determinations of the prothrombin time twice daily. (Arch. Int. Med., Feb. '45 - 
Van Dellen et al ) 

****** 

Repair in Sprains and Fractures Treated bv Novocain Injections : The 
method of treating sprained and fractured ankle joints by novocain infiltration 
and early mobilization, as advocated .by Leriche, has gained wide usage. Re- 
ports have been in agreement as to the reduction in the severity of the symp- 
toms and in the period of disability following the use of this form of treatment. 
The use of local anesthesia at the time of initial examination may be of con- 
siderable importance as an aid in the diagnosis of rupture of the lateral liga- 
ments of the ankle joint. 

Bohm and Flyger (Acta Chirurg. Scand.) recently have studied the effect 
of novocain infiltration upon repair of experimentally-produced fractures. A 
series of fibular fractures in rats was treated by local injection of one per 
cent novocain. During the first week injections were given each day, in the 
second week every other day, and in the third week every third day. In these 
animals maximum hyperemia was reached in ten days as compared with 
25 days in the controls. The most striking feature, however, was the effect on 
the actual process of repair of the fractures. In the treated cases, consolida- 
tion of the callus was present after 25 days, whereas in the controls, the callus 
at this period was still spongy, and in some cases still in the stage of connec- 
tive tissue repair. 



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Burned News Letter, Vol. 5, No. 9 RESTRICTED 



Survival PerioH of Mm Tmmer ^d is Hold Water: Physiological responses 
to immersion in cold water and the protective value of watertight suits were dis- 
cussed in the Burned News Letter of September 3, 1943. Further observations 
have been made on the rate of c ooling of the bodies of men and of animals 
immersed to the level of the neck in water at various temperatures for the pur- 
pose of estimating the survival time of men forced into the water at sea. 

Since the rectal temperatures of men tend to stabilize at from 35° to 36° C. 
following immersion in moderately cold water (20° to 30° C.) , there is little im- 
mediate danger that fatal hypothermia will occur under these conditions It is 
probable that rectal temperatures would continue at this level until the shiver- 
ing mechanism became fatigued. This would not occur soon in water at 30 C, . 
or even in water at 25° C. However, with water at 20° C, shivering is quite 
violent and the metabolism is about five times that of the basal level. While it is 
likely that shivering could be maintained at this intensity for several hours , shiver- 
ing is distinctly fatiguing, and it seems likely that watet as cold as this should be con- 
sidered dangerous to men who may be immersed in it for prolonged periods. 
With colder water (10° to 15° C.) rectal temperatures decline rapidly to lo w 
levels. In one subject the rectal temperature reached 33.5° C. after a little 
more than one hour of exposure, with no indication that body temperature would 
become stabilized. It is not likely that a rectal temperature much lower than 
this would be compatible with survival of men floating in the ocean when some 
alertness and physical exertion would be necessary to avoid drowning. T hi s 
subject was able to get out of the water tank unaided at the termination of the 
experiment- however, considerable muscular weakness and moderate vertigo 
were present. This was not unexpected, for others have reported some func- 
tional impairment in men with rectal temperatures slightly above 30" C, and 
severe impairment with rectal temperatures compatible with survival in the 
situation under consideration. Experiments were not made with still colder 
water because of discomfort and possible danger to the subjects; however, 
judging from the behavior of animals and from physical laws of cooling, it is 
estimated that the rectal temperatures of men immersed in water at 0 would 
reach 30° C. in about half the time that it would take for subjects immersed m 
water at 15° C, It may be that cooling occurs even more rapidly than this in 
extremely cold water, for cases have been reported of death occurring within 
a few minutes following immersion in the ocean in northern latitudes. It l s 
possible, however, that death in these cases resulted from drowning following 
fainting due to the shock of the exposure rather than from hypothermia. 

Some objection might be raised regarding these estimates since they -are 
based upon data obtained from nude subjects at rest. However, it has been shown 
that ordinary clothing is of little value in preventing body cooling of men im- 
mersed in water. When the subjects were encouraged to swim as vigorously as 
possible, they cooled as rapidly as they did at rest. Probably the exercise was 
of no benefit because heat production is already maximum under these conditions 



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Burned News Letter, Vol. 5, No. 9 



RESTRICTED 



as a result of shivering. The subjects were men of medium size (average 
weight, 63.5 kg.). Larger men might be expected to be more resistant to cool- 
ing because of relatively smaller surface area in relation to cooling. It is 
possible, for example, that some men might be able to avoid body cooling for 
many hours, even in the coldest water, as was the case with one of the dogs 
which was studied. Because of these facts and because of the incomplete na- 
ture of the data which was obtainable on man, the estimates of survival time 
given above must be considered to be only approximately correct. (Nav Med 
Res. Inst., Proj. X-189, Report #3, Feb. 3, '45) 

****** 

Traumatic Rupture of the Spleen: Since the mortality rate for cases of 
ruptured spleen may be reduced by operation from 93 per cent or higher to 10 
per cent, the importance of early diagnosis is evident in order that surgical 
intervention may be instituted without delay. 

In traumatic rupture of the spleen one of two clinical pictures maybe 
manifest: 

1. A rapidly progressive hemorrhage immediately following the injury 
may be accompanied by the following symptoms and signs, in descending order 
of frequency: generalized abdominal pain, 100 per cent; tenderness, 95 per cent; 
rigidity, 85 per cent; shock, 65 per cent; dulness on percussion, 50 per cent;' 
vomiting, 35 per cent; localized pain, 30 per cent; and abdominal distention, 15* 
per cent. A history of trauma to the left upper quadrant of the abdomen, when 
combined with the aforementioned signs, is strongly suggestive of rupture of the 
spleen. 

Few signs are pathognomonic of rupture of the spleen. Irritation of the 
left diaphragm by accumulation of blood may cause abdominal pain with radia- 
tion to the left scapula (Kehr's sign). Roentgenograms may reveal increased 
density in the affected region and abnormal elevation of the left side of the 
diaphragm, in addition to displacement of the stomach to the right or compres- 
sion of the fundus. Palpation discloses a tender, indefinite mass in the left 
upper quadrant of the abdomen. Dulness on percussion may be present not 
only in the left upper quadrant and the left flank but also in the right flank; on 
shifting the patient's position, the dulness in the right flank disappears (Ba- 
lance's sign). 

In the differential diagnosis one should consider fracture of the lower ribs 
on the left side, traumatic pleurisy, laceration of the liver or the left kidney, 
and rupture of a hollow viscus. Simple contusion of the abdominal wall without 
injury of the internal organs does not affect the pulse rate, the blood pressure 
or the erythrocyte count. In doubtful cases, Wright and Prigot advocated diag- 
nostic tapping of the abdomen. 



- 18 - 



Burned News Letter, Vol, 5, No. 9 RESTRICTED 

2 An asymptomatic or latent period, after recovery from the initial in- 
jury which may be trifling, is followed by a delayed, recurrent hemorrhage 
The usually abrupt onset of the secondary hemorrhage initiates a clinical 
syndrome consisting of abdominal pain, rigidity and tenderness, soon followed 
by shock or collapse. However, the secondary hemorrhage may not start dra- 
matically with acute symptoms of loss of blood but may have an insidious 
onset. 

Zabinski and Harkins have stated that the ratio of incidence of delayed to 
immediate grave hemorrhage is 1 to 6. Great diagnostic difficulties are en- 
countered in cases of delayed splenic hemorrhage. The apparent well-being 
of the patient during the latent period may create a false sense of security and 
may cause the attending physician to minimize the gravity of the situation. 
(Arch. Surg., Feb. '45) 



Section of Vagus Nerves in Peptic Ulcer : The presence of gastric secre- 
tory and motor fibers in the vagi and the large volume of experimental and 
clinical evidence indicating the crucial importance of gastric juice in the gene- 
sis of ulcer led Dragstedt and his associates to undertake complete division of 
the vagus nerves leading to the stomach in eleven cases of peptic ulcer. This 
was found to be most readily accomplished by opening the left pleural cavity, 
exposing the lower esophagus and isolating and dividing the vagus fibers before 
they pass through the diaphragm. The operation was well tolerated; there were 
no deaths and the most serious complication was a postoperative pneumonia in 
one case. Gastrointestinal motility was not greatly altered, neither constipation 
nor diarrhea was produced, and it appeared that food traversed the intestinal 
tract without great delay. Fluoroscopy after the operation revealed the persist- 
ence of peristalsis in the esophagus and the absence of cardiospasm, but in one 
case considerable atony in the wall of the fundus of the stomach was seen. No 
abnormalities in the motility or tonus of the small intestine could be deter- 
mined. The continuous night secretion in most of the cases before operation 
was abundant, and in seven of the cases it exceeded a liter in twelve hours. This 
secretion was reduced by over 50 per cent following the vagus section mall cases 
and in many to a still greater degree. It is believed that this provides final proof 
that the hypersecretion of gastric juice in cases of ulcer is neurogenic in origin 
and is probably due to a continuous hypertension of the gastric secretory fibers 
in the vagus nerves. The striking relief of the ulcer pain and distress secured 
by the operation, the absence of untoward sequelae and the decrease in gastric 
secretion all indicate that this procedure will find a place in the treatment of 
many cases of intractable peptic ulcer. This investigation was started only 
eighteen months ago, and further observation will be required before the final 
results may be evaluated. (Gastroenterol., Dec. '44) 



- 19 - 



! 



Burned News Letter, Vol. 5, No. 9 RESTRICTED 



Enterogastrone in P eptic Ulcer : Ivy applies the term enterogastrone to 
the chalone or hormonal agents which are responsible, in part at least, for the 
inhibition of gastric secretion and motility when an adequate amount of fat or 
sugar is ingested. Enterogastrone is produced primarily in the upper intestine. 
Ivy has found that the parenteral administration of a mucosal extract of the upper 
intestine of swine prevents the occurrence of gastro jejunal ulcer in a high per- 
centage of Mann- Williams on dogs. The protection is not limited to the period 
during which the extract is being administered, but has been observed to ex- 
tend for periods as long as three years after cessation of treatment. Forty- 
three patients have received injections of enterogastrone to date. In five the 
injections were stopped because the patients complained of pain. The patients 
selected for study had a long history of recurrent ulcer distress. 

The direct control of acid secretion in man by this method awaits the pro- 
duction of a preparation of enterogastrone which contains less impurity than 
the present preparation. However, results obtained so far have been encourag- 
ing. Four patients who received only enterogastrone therapy six times weekly 
for four months are now free from symptoms and of an ulcer niche demonstrable 
by roentgenographs examination, and the duodenal deformity has lessened in two. 
Among 21 patients who had received injections three times weekly for seven to 
twelve months, four have had one period of distress. The average expected re- 
currence of ulcer distress, on the basis of the past history, was reduced from 
21 to 4 during a six-months' period. Further observation for a period of sev- 
eral years of a larger series of patients will be required to obtain reliable in- 
formation on the late effects of this treatment. (Gastroenterol., Dec. '44) 

****** 

The Cocc idioidin Skin Test in an Epidemiologic Survey: The clinical as- 
pects of coccidioidomycosis and the value of the coccidioidin skin test in 
diagnosis were presented in the Burned News Letter of October 29, 1943. 

It is the consensus that a positive skin test has the same significance in 
coccidioidomycosis that a positive tuberculin test has in tuberculosis; it indi- 
cates that the patient has, or has had some time in the past, a coccidioidal in- 
fection, either clinical or subclinical. 

The coccidioidin skin test becomes positive from the tenth to the f orty- 
fifth day after exposure, and tends to parallel the appearance of other manifesta- 
tions of hypersensitivity in this disease, such as erythema nodosum, erythema 
multiforme, conjunctivitis, and arthritis. Patients with these clinical manifesta- 
tions (valley fever) , are highly sensitive to coccidioidin, and Wallgren's concept 
of tuberculin sensitivity is believed to have a parallel in this disease. Also it 
has been shown that in the majority of instances, the cutaneous sensitivity per- 
sists. The specificity of the coccidioidin skin test and the absence of 



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Burned News Letter, Vol. 5, No. 9 



RESTRICTED 



cross-sensitivity to tuberculin have been well established. Some cross- 
sensitivity to a fungus, Haolosporagium parvum , isolated from rodents m 
Arizona, has been reported, and it has been observed that residents of some 
middle western states may show a borderline positive coccidioidin skin test 
which may be the result of exposure to another fungus which is as yet undenti- 
fied. 

From an epidemiological standpoint the test remains the most feasible 
method for determining the relative degree of infection with Coccidioides 
immitis among the residents of a given community. The results of coccidi- 
oidin skin testing, together with reports of clinical cases of the disease, show 
the endemic areas in the United States of coccidioidal infection to be the south- 
ern half of California, particularly the San Joaquin Valley, southern Arizona 
and western Texas. In addition, there is an endemic area in the Chaco region 
of Argentina, and possibly another in Italy. It has been suggested that the re 
may be unrecognized endemic areas in other warm, dry, dusty regions of the 
world. 

A survey was undertaken among the officer personnel of a military hospi- 
tal at Modesto, California, in the northern end of the San Joaquin Valley, using 
the coccidioidin skin test as a means of determining the incidence of coccidi- 
oidal infections in that region. Five hundred and seventeen tests were per- 
formed on a total of 360 officers, 157 of them being re-tested one or more 
times. The total incidence of positive reactions was 4.8 per cent, but only 
1 7 per cent of all the positive tests occurred in personnel who were unques- 
tionably infected while at the post. Apparently only 10 of 360 subjects studied, 
(2 8 per cent)' contracted the infection while resident in the area , which would 
indicate that the degree of coccidioidal infection at this post is relatively slight. 
It is of interest that during the period of observation no one -on the post deve- 
loped clinical pulmonary coccidioidomycosis as could be determined by roent- 
genograph^ examination of the chest, complement-fixation test or sputum ex- 
amination. There was a noticeable tendency for the positive reactions in this 
series to decrease in degree of intensity, or to become negative when repeated 
six and twelve months later. The reason for the diminution or loss of cutane- 
ous sensitivity in some persons is unknown. (Mil. Surg., Feb. '45, Cheney 
and Denenholz) 



Erratum: In the article, "Water Purification", page 23 of the April 13, 
1945, issue of the Burned News Letter, lines 18 -21 should read: "Also, water 
may be sterilized in Lyster bags by adding two canteen caps full of tincture of 
iodine to one Lyster bag full (36 gallons) of water, or water may be boiled in 
GI cans and, after cooling, poured into Lyster bags for dispensing. 



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Burned News Letter, Vol. 5, No. 9 REST RICTED 



Bath Dermatitis: A dry, erythematous, scaling, itching eruption occurs 
commonly in personnel recently returned from, the tropics. It usually begins 
on shipboard or within a few days after return to the States, and is the result 
of increased bathing with hot water and a decreased activity of the sebaceous 
glands which are adjusting to a cool climate after having^been acclimated t o 
tropical heat. The eruption occurs most frequently about the waist, over the 
lateral surfaces of the hips, and on the anterior surfaces of the thighs, or it 
may be generalized. 

When treated with strong fungicidal or parasiticidal drugs - because of 
error in diagnosis, the condition rapidly becomes worse, and may become in- 
capacitating. 

It is readily controlled by less frequent bathing, by avoiding the use of 
soap on the affected areas, and by application of any bland emollient such as 
cold cream. (J. W. Bagby - USNH, Oakland, Calif.) 

****** 



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Burned News Letter, Vol. 5, No. 9 RESTRICTED 

To: All Ships and Stations. BuMed- C-LET- 

P7/OG 

Subj: Navy Nurse Corps, Marriage of Officers of. 22 Feb 1945 

Ref: (a) BuMedltr P7/OG, of 23 Jan 1945; N.D. Bui. of 31 Jan 1945, 45-86. 

1. The following changes will be made in reference effective immediately: 

(a) Par. 2, strike out the words "or has been" so that the first part of this 
paragraph shall read: "When it shall be determined that an officer of the Nurse 
Corps is pregnant in the naval service, the following procedure shall be adopted 
to effect separation from the service:". 

(b) Par. 2(d), strike out the words "or has been." 

(c) Par. 2(e) , change to read as follows: "Action (which will include orders 
home on acceptance of resignation) normally will be taken by letter." 

(d) Par. 2(f) strike out. 

--BuMed. W. J. C. Agnew. 
* * * * * * 

All Ships and Stations. BuMed- Y-vh 

A3-3/EN10 

Discontinuation of Monthly Communicable Disease 
Report; Establishment of Monthly Morbidity Report 22 Feb 1945 
(Form NavMed 582) . 

(a) BuMed- Y, A3-3/EN10Q04-40) , of 21 Dec 1944; N.D. Bui. of 31 Dec 
1944, 44-1448. 

(b) BuMed- Y-vh, A3-3/ENlO(F) , of 23 Feb 1945; 45-298, this issue. 

(c) Par. 2695, Manual of the Medical Department. 

(d) Par. 3517, Manual of the Medical Department. 

(A) Sample copy of NavMed 582. 

1. The Monthly Report of Communicable Diseases (letter form) is directed to 

be discontinued as of 1 April 1945. References (c) and (d) are therefore canceled 
effective the same date. 

2. Reference (a) discontinued the monthly (smooth) form F (Abstract of Patients). 

3. The purpose of the discontinuation of these forms is to reduce the volume of 
work in the field. NavMed form 582 (Monthly Morbidity Report) is herewith 
established and it shall be used effective 1 April 1945 (report for month of April). 
This form is intended to replace the two canceled reports, and has been designed 
to provide the Bureau with abstracted statistical data in such form as to meet 
current requirements. 



To: 
Subj: 

Refs: 
End: 



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Burned News Letter, Vol. 5, No. 9 RESTRICTED 



4. Effective 1 April 1945 (i.e., report for the month of April), NavMed form 
582 (Monthly Morbidity Report) shall be completed in duplicate as soon after 
the end of each month as possible but not later than the tenth of the following 
month. The original of this form shall be forwarded via air mail to BuMed by 
all activities having Medical Department personnel (including all expeditionary 
groups and field activities). A copy shall be retained on file' by the reporting 
activity. It shall also be prepared and forwarded for the active part of the 
month, whenever a ship is decommissioned or a shore activity is disestablished. 

5. Reference (b) establishes four additional methods of taking up on the sick 
list and redefines the old methods. The new methods are: FT (FROM TRANS^ 
FER); AD (ADDITIONAL DIAGNOSIS); EC (DIAGNOSIS ESTABLISHED OR COR- 
RECTED); and FS (FORMER STATUS). NavMed 582 is designed to conform 
with these additions. 

6. This directive does not affect NavMed form F card (Individual Statistical 
Report) procedure in any way. 

7. A supply of -blank NavMed 582 forms with specific instructions for their 
preparation is being furnished each activity. At activities where the receipt 
of these blank forms may be delayed beyond 1 May 1945, the report shall be 
prepared and submitted in letter form monthly until the arrival of the printed 
forms. Form NavMed 582 will be stocked at all naval medical supply depots 
and storehouses and will be listed in the Medical Supply Catalog as follows: 



Stock No. NavMed No. Item Title Unit 

S16-3990 582 Monthly Morbidity 50 in pad 

Report 

8. On 1 April 1945, each activity having Medical Department personnel at- 
tached shall submit a belated Monthly Morbidity Report (Form NavMed 582) 
for the months of January, February, and March, 1945. Inasmuch as the new 
methods of taking up on the sick list were not in effect during that time interval, 
only the following data shall be reported for those months: 

(a) Average strength for the month. 

(b) Patients remaining on sick list at end of the month. 

(c) In Part I - report only totals for the month under headings "A", 
"ACD" , "D", "DD", "IS". 

(d) Part II - report totals for each line under heading "A". 

--BuMed. W. J. C. Agnew. 



- 24 - 



MONTHLY MORBIDITY REPORT 

NAVMEO-SB2 (MS) 



(Nam* and location of thip or itaUim) 



SUBMITTED _ 



MONTH ENDING. 



194- 



FOR WARDED_ 



(Swiwiur. M.O.) 



USN. 



.USN, 



Part I 



AVERAGE STRENGTH 



WHITE 
NEGRO 
TOTAL 



TOTAL PATIENT 
SICK DAYS 
DURING MOUTH . 



ALL 
DIAGNOSES 


TAKEN UP ON SICK LIST DURING MONTH AS 


SICK LIST AT END OF MONTH 


A 


HA 


ACD-AD 


EC 


FT 


FS 


NAVY OFFICERS 

















MARINF OFFICERS 
















HAW FNI ISTFn 


ALL 
DIAGNOSES 


DISPOSED FROM SICK LIST DURING MONTH AS 


M4R1NF FNI ISTFn 


D 




DD 


IS 


RAN 


T 


TOTAI 


TOTAL 














■SIIPFRNIIMFRiRIFS 



Part II 



NUMBER TAKEN UP DURING THE MONTH 
ACCORDING TO DIAGNOSTIC CLASS AND SELECTED DIAGNOSES 



0 
z 

UJ 




NO. TAKEN UP DURING THE MONTH AS || ° 


D 


AGNOSTIC CLASS AND 


NO, TAKEN UP I 


JURING 


THE Ml 


3NTH AS 


DIAGNOSTIC CLASS AND - 
DIAGNOSIS 


A 


RA 


ACD- 
AD 


EC 


FT 


FS 


3 


DIAGNOSIS 


A 


RA 


ACD- 
AD 


EC 


FT 


"S 


P 

SL 

02 


:LASS1: diseases of 

BLOOD 
















XASS D£: COMMUNICABLE DISEASES 
TRANS. BY INTESTINAL DISCHARGES 














CLASS II: DISEASES OF 
CIRCULATORY SYSTEM 














25 


DYSENTERY, BAC1LLARY 
















26 


PARATYPHOID FEVER 














to 


CLASS III: DISEASES OF 
DIGESTIVE SYSTEM 














27 


TYPHOID FEVER 
















28 


ALL OTHER DISEASES 










1 


w 


CLASS IV: DISEASES OF 
DUCTLESS GLANDS. SPLEEN 
















CLASS X: COMMUNICABLE DISEASES 
TRANS. BY INSECTS. ARTHROPODS 












05 


CLASS V: DISEASES OF 
EAR, NOSE. AND THROAT 














29 


DENGUE 












30 


FILARIASIS 
















CLASS VI; DISEASES OF 
EYE AND ADNEXA 














31 


MALARIA, BENIGN TERTIAN 














32 


MALARIA MAUG. TERTIAN 














06 
07 


CLASS VII: DISEASES OF 
GENITO-SIRINARY SYSTEM (NONVENEREAL) 














33 


MALARIA. DUARTAN 














34 


MALARIA, MIXED 
















CLASS VLIIA; COMMUNICABLE DISEASES 
TRANS. BY ORAL AND NASAL DISCH. 








35 
36 


MALARLA, UNSPECIFIED 
















TYPHUS, ENDEMIC (FLEA>OORNE) 












06 


CEREBROSPINAL FEVER, MENINGO. 










■ 




37 


TYPHUS. EPIDEMIC {LOUSE-BORNE) 














09 


DIPHTHERIA 














38 


TYPHUS, SCRUB (MITE-BORNE) 














10 


GERMAN MEASLES 














39 


ALL OTHER DISEASES 














II 


INFLUENZA 
















CLASS XI: 
TUBERCULOSIS 




12 


MEASLES 




















1 




13 


MUMPS 














ffi 




PULM. PRIMARY, ACTIVE 














U 


PNEUMONIA. BRONCHO- 














41 


PULM. PRIMARY, HEALED 














IS 


PNEUMONIA. LOBAR 














42 

' 13 


E 

. s 


PULM. REINFEC., ACTIVE 














16 


PNEUMONIA, PRIM., ATYPICAL 












PULM. REINFEC, ARRESTED 














17 
IS 


POUOMYELITIS, ANT., ACUTE 














44 




ALL OTHER DISEASES 














SCARLET FEVER 














45 




PULM. PRIMARY, ACTIVE 












19 


SMALLPOX 










46 


- 8 


PULM PRIMARY. HEALED 
















CLASS V1IIB: INFECTIOUS DISEASES, 
RESPIRATORY 








47 
48 


* {J 

;1 


PULM REINFEC, ACTIVE 
















PULM. REINFEC. ARRESTED 














20 


ANGINA, VINCENTS 














49 




ALL OTHER DISEASES 
















CATARRHAL FEVER, ACUTE 
















Continue J on reverse side 




Z 

z 


- — < ? 

PHARYNGITIS. ACUTE 
















TONSILLITIS, ACUTE 
















24 j ALL OTHER DISEASES VHIA AND flj 

















NUMBER TAKEN UP DURING THE MONTH 
ACCORDING TO DIAGNOSTIC CLASS AND SELECTED DIAGNOSES 



3 


[ 

DIAGNOSTIC CLASS AND 
DIAGNOSIS 


No.T 


AKEN UP DURI 


4G THE MONTH AS 


d 

Z 


DIAGNOSTIC CLASS AND 
DIAGNOSIS 


No. TAKEN UP DURING THE MONTH AS 


A 


RA 


ACD- 
AD 


EC 


FT 


F£ 


LINE 


A 


RA 


ACD- 
AD 


EC 


FT 


FS 




CLA 
VEM 


55 XII: 

KEAL DISEASES 






77 


CLASS XVIII: DISEASES OF 
RESPIRATORY SYSTEM 














HI 

w 

52 
53 


WHITE 


CHANCROIDAL INFECTIOUS 
















CLASS XIX: DISEASES OF 

skIn unit; ANn NJirc 














SONOCOCCU5 INFECTIONS 














73 


SYPHILIS. EARLY 
















CLASS XX; 
HERNIAS 














ALL OTHER DISEASES 














79 


54' 

55* 
56 
£7 


0 
K 

13 
U 


CHANCROIDAL INFECTIONS 
















CLASS XXJ: MJSCFLUNLOU5 
DISEASES AND CONDITIONS 














GONOCOCCUS INFECTIONS 


















SYPHILIS, EARLY 














90 


DIAGNOSIS UNDETERMINED 
















ALL OTHER DISEASES 
















FATIGUE, COMBAT 
















CLASS XIII: OTHER DISEASES 
OF INFECTIVE TYPE 




82 


FATIGUE, OPERATIONAL 


















63 


ALL OTHER DISEASES 














58 


DYSENTERY. UNCLASSIFIED 
















CLASS XXII: PARASITIC 
DISEASES 














59 


FOOD INFECTION 
















60 


FOOD INTOXICATION 














84 


ASCARIASIS 














61 
62 


FOOD 
GAS I 


POISONING 














S5 


AMEBIASIS 














ACILLU5 INFECTION 














66 


COCCID105IS 














S3 


JAUNDICE. ACTIVE. INFECTIVE 














87 


FUNGUS INFECTION, SKIN 














64 


JAUNDICE, EPIDEMIC (WEIL'S) 














86* 


SCHISTOSOMIASIS 














65 
66 


RHEU 
TETAB 


HAT1C FEVER 














89 


1ENMS1S 














US 














90 


ALL OTHER [MSEASES 














67 


YAWS 
















CLASS XXIII' 
TUMORS 














63 


ALL OTHER DISEASES 














ES 


CLASS XIV: DISEASES OF 
LYMPHATIC SYSTEM 
















CLASS XXIV: FEMALE 
DISEASES AND CONDITIONS 
















CLASS XV: DISEASES OF 
THE MIND 








PI ACQ VW- 
UJWJ AAV! 

INJURIES 










70 


CONST1T, PSYCHO, INFERIORITY 














93 


"V" flrj IE IE3IET £l\ 

n \ in J U ti 1 Li 1 












71* 


PERSONALITY DISORDER 














94 


ALL OTHERS 














72* 
73* 


PSYC 
PSYC 


■IONEUROSES 
















CLASS XXVI: 
POISONINGS 










DOSES 
















74 


ILL OTHER DISEASES 














95 


"K" (POISONINGS) 












JS 


CLASS XVI: DISEASES OF 
rlOTOIi SYSTEM 














96 


ALL OTHERS 
















D 


:LASS XXVII: DENTAL 
DISEASES AND CONDITIONS 














c 

76 1 


:USS XVII: DISEASES OF 
(EEVOUS SYSTEM 

























INSTRUCTIONS: 

1. forward original to the Bureau of Medicine and Surgery before the 10th day following end of report month via Air Mail 
(Red Stripe Air Mail if available.) Classify only when necessary. 

2. Report each admission or change of status (taken up as A, RA, A CD, AD, EC, FT, PS) which occurred during the report 
month whether or not the case was disposed of during that month. 

3. Count number of sick days accumulated during the report month by each patient (exclusive of supernumeraries) whether or 
not the patient was taken up or disposed of during the month. Total for all patients ia "total patient sick days during month." 

4. If no other location of activity can be given, report Navy Number. 

5. Average strength must be reported. (For method of computation see par. 3503.4 Manual of the Medical Department. 1945 
revision.) . 

6. Include other races (Indian, Filipino, etc.) with white wherever racial data is required. 

7. Report the number of supernumeraries "on the sick list at end of month" on the line indicated. Do not include supernumer- 

8. Where diagnostic class alone is given, report totals of all diseases for that class. 

9. For "all other diseases" report total of all diseases for that class except those listed separately. 

10. Do not use zeros to indicate that no cases have occurred, Leave blank. Check all entries for accuracy. 

•Note.— Each specific diagnostic title corresponds to a single title in the Navy Diagnostic Nomenclature (1945 revision). Exception* 
are as foLlows: Lines 42 and 47 include diagnoses 1123, 1124, 1125; fines 43 and 48 include diagnoses 1133, 1134, 1135; fines 50 
™ im itLVT. 1 ? 11 ; 12 , 02; lmes 51 and 55 in «lude diagnoses 1211 through 1216, inclusive; Line 71 includes diagnoses 
l«tt, 15b2, 1564; line 72 mcludes diagnoses 1531, 1541 through 1545, inclusive; line 73 includes diagnoses 1501 through 1504, 1511 
through 1518, 1521 through 1527, inclusive; line 88 includes diagnoses 2228, 2229, 2230. 



MONTHLY MORBIDITY REPORT (BACK) NAVMED-SU CMS) 

- iSD - 



Burned News Letter, Vol. 5, No. 9 RESTRICTED 



ALNAV 54 

Subj: Detachment of Officers. BuPers (312B) 28 Mar 1945 

Hereafter commissioned and warrant officers requiring hospitalization for 
indefinite period with return to regularly assigned duty improbable will be 
issued written orders by commanding officer or reporting senior directing of- 
ficer report MOINC appropriate hospital giving location. Include in such orders 
definite statement detaching officer from permanent duty station. 

Request for relief if necessary may be part of orders or separate corres- 
pondence. Furnish BuPers copy. Classify orders if necessary for' security. 
Medical officers in command of hospitals forward NavMed Form 1 to BuPers 
in accordance current instructions indicating thereon permanent duty station 
from which officer detached or other status such as traveling under orders or 
on leave. 

Whenever officer who was detached from permanent duty station upon admis- 
sion is fit for duty request disposition from BuPers instead of returning to for- 
mer command or comply BuPers circ. ltr. 133-44 if appropriate. BuPers circ. 
ltr. 179-44 hereby canceled. --SecNav. A. L. Gates. 



To: All Ships and Stations. BuMed-Y-DFS 

P3-3/P3-1 

Subj: Reporting of Photofluorographic Chest Examinations.' 10 Mar 1945 

Ref: (a) BuMed ltr P3-3/P3-K054-40) , of 24 Jun 1942; N.D. Bui. Cum. Ed. 
1943, 42-237, p. 436. 

1. Paragraphs 5, 6, 7, and 8 of reference (a), which requires the blanket and 
quarterly report of findings of all chest examinations, are hereby canceled. 

--BuMed. Ross T. Mclntire. 

****** 

To: All Ships and Stations. BuMed-C-LET 

HJ/L16-7 

Subj: Red Cross Personnel Assigned to Navy, Marine Corps 17 Mar 1945 
and Coast Guard Activities - Official Status of. 

1. In accordance with the act of 29 June 1943 and articles 1470-1478, Navy 
Regulations, Red Cross personnel are assigned by Red Cross National Head- 
quarters to duty at various activities of the Navy, Marine Corps and Coast 
Guard. Similar assignments are made to the Army. 



- 27 - 



Burned News Letter, Vol. 5, No. 9 RESTRICTED 



2. The Red Cross uniformed professional staff consists of (1) field directors, 
assistant field directors, and assistants to the field director; (2) social workers; 
(3) recreation workers; (4) hospital workers or staff aides; and (5) secretaries, 
when on duty outside continental United States. 

3. In order to establish a uniform personnel policy for all activities of the Navy, 
Marine Corps and Coast Guard and in order that such policy may be in conso- 
nance with existing directives of the War Department, the following instructions 
will govern the personal relations of Red Cross professional uniformed staff 
with the Navy, Marine Corps and Coast Guard: 

(a) In general, if conditions and facilities permit, commanding officers are 
authorized to extend to the personnel listed in paragraph 2 above the following 
privileges and courtesies on the same basis as these are extended to commis- 
sioned personnel, subject to certain necessary modifications, as hereinafter set 
forth: 

(1) Ship's store and Ship's Service facilities 

(2) Commissary stores 

(3) Subsistence - messing facilities 

(4) Quarters 

(5) Medical care 

(6) Purchase from supply officers (in certain areas where other sales 
agencies have not been established and sales to personnel attached to a naval 
activity have' been" specifically authorized). 

(b) Ship's store and ship's service facilities. Such privileges may be ex- 
tended to Red Cross personnel attached to or taking passage on a naval or a 
Coast Guard vessel or assigned to a Navy, Marine Corps or Coast Guard acti- 
vity. The families and dependents of such Red Cross personnel may be extended 
similar privileges as are extended to dependents of service personnel attached 
to the station. 

(c) Commissary store. Pursuant to the authority previously granted by 
the Secretary of the Navy commissary store privileges have been extended to 
uniformed Red Cross personnel performing duties at naval activities both inside 
and outside of the continental limits of the United States. 

(d) Subsistence - messing facilities. Red Cross uniformed personnel may 
be accorded the privilege of the officers' mess of the ship or station to which 
attached or when in transit in a Navy or Coast Guard vessel, by payment of the 
same charges as are made to or for commissioned officers using the mess. 
This also applies to hospital ships and to naval base and fleet hospitals. In 
naval hospitals and naval convalescent hospitals the charge for subsistence will 
be as specified in the Manual of the Medical Department. On stations their de- 
pendents will be accorded such officers' mess privileges as are available to 
officers attached to the station. 



Burned News Letter, Vol. 5, No. 9 



RESTRICTED 



(e) Quarters. Aboard ships Red Cross uniformed personnel will be as- 
signed quarters as in the case of commissioned officers. Within the continen- 
tal United States, living quarters in bachelor officers' quarters, as practicable, 
or other public quarters may be provided attached Red Cross uniformed person- 
nel when available and when adequate quarters are not available outside the res- 
ervation . By "adequate" quarters is meant suitable and available quarters 
within a reasonable distance from the station with satisfactory transportation 
facilities. Such quarters, when assigned, will be assigned without charge where 
no charge is made to commissioned naval personnel occupying similar quarters. 
Where a charge is made to naval personnel for quarters, it is expected that Red 
Cross uniformed personnel will meet such charges. 

CD Medical care. Red Cross uniformed personnel serving at Navy, Marine 
Corps, or Coast Guard activities within the continental United States shall be 
afforded necessary first-aid measures and emergency hospitalization. For medi- 
cal care and treatment other than admission as in-patients (hospitalization) to 
naval hospitals or naval dispensaries, no charge shall be made. For hospitaliza- 
tion Red Cross personnel shall make payment at the interdepartmental reciprocal 
hospitalization rate fixed annually by the Federal Board of Hospitalization, and 
collection of this hospitalization charge shall be made locally in accordance with 
existing instructions regarding hospitalization of supernumerary patients. When 
serving in a locality where civilian medical service is not obtainable, as on 
board naval vessels and in certain instances outside the continental limits of 
the United States, Red Cross uniformed personnel shall be afforded without charge 
the same medical treatment as is afforded naval personnel, except that dental 
treatment shall be limited to that required for the relief of pain or other emer- 
gency measures. 

4. Within the continental United States the non-uniformed clerical staffs of the 
Red Cross employed by the Red Cross and working in the Red Cross offices 
within an activity of the Navy, Marine Corps or Coast Guard may be accorded 
only such of privileges and facilities above described as are available to the 
civilian employees of the activity and subject to such charges as civilian em- 
ployees are required to pay; provided, however, the non-uniformed Red Cross 
personnel shall not purchase provisions or other stores from Navy commissary 
stores or from other Navy supply activities unless specifically authorized by 
the Secretary of the Navy in accordance with article 1309-3, Bureau of Supplies 
and Accounts Memoranda. 

5. The foregoing privileges may be extended only upon proper identification of 
Red Cross personnel or their families and/or dependents and upon written per- 
mission of commanding officers. 

6. Any existing regulations or portions thereof which may be in conflict with 
this letter are hereby modified and superseded accordingly.- 



- 29 - 



Burned News Letter, Vol. 5, No. 9 RESTRICTED 



7. The following circular letters issued by the Bureau of Medicine and Surgery- 
are specifically modified and superseded to the extent that they may be in con- 
flict with this letter: 

Ca) Assignment of Quarters to Red Cross Personnel Attached to Hospital - 
HJ/L16- 7(042), 7 Feb 1944, addressed to All NavHosps, NavConvalHosps, Naval 
Base Hospitals and Fleet Hospitals. 

(b) Assignment of Red Cross Personnel with Medical Department in Over- 
seas Service - HJ/EF(032), 12 Jul 1944; N.D. Bui. of 15 Jul 1944, 44-805. 

8. The Bureau of Naval Personnel regulations for Ship's Service departments 
ashore are specifically modified to the extent that they may be in conflict with 
this letter. --SecNav. H. Struve Hensel. 

***** * 

To: All Ships and Stations. BuMed-C-LET 

A18-1/OG 

Subj: Discharges, Navy Nurse Corps 2 Mar 1945 

Refs: (a) Manual of the Medical Department, 1938, par. 453. 

Cb) Opinion of JAG as approved by ActSecNav, 13 Feb 1945. 

1. Subparagraph (c) of reference (a) reads: "(c) Orders to proceed home will 
not be given to a nurse under the following conditions: (1) Prior to expiration 
of 3-year period of duty; (2) prior to completion of required tour of duty at a 
station involving extensive travel, to which a nurse has been transferred at 
her own request; (3) for insubordination or other misconduct, subject to the 
provisions noted in paragraph 454(c)." 

2. In reference (b) it is held: (a) That inasmuch as members of the Navy Nurse 
Corps for the period of the present war and for 6 months thereafter have the 
rank of and receive the pay and allowances of commissioned officers, they are 
included within the scope of section 12 of the act of 16 June 1942, as amended by 
the act of 7 September 1944, which provides as follows: 

. "Officers of any of the services mentioned in the title of this Act, including 
active and retired personnel of the Regular Establishments and members of the 
Reserve components thereof and the National Guard, while on active duty in the 
Federal service, when traveling under competent orders without troops, includ- 
ing travel from home to first station in connection with their appointment or call 
to active duty and from last station to home in connection with relief from active 
duty or discharge not the result of their own misconduct, shall receive a mileage 
allowance at the rate of 8 cents per mile, * * * " (italics supplied.) 

(b) That although the marriage of a member of the Navy Nurse Corps prior 
to completion of a 3-year period of duty or prior to expiration of the required 



- 30 - 



Burned News Letter, Vol. 5, No. 9 RESTRICTED 



tour of duty after extended travel is a violation of the agreement under which 
the member entered the Navy or proceeded to the distant station, such act does 
not constitute misconduct; and (c) that since members of the Navy Nurse Corps 
may be discharged not the result of their own misconduct prior to the expiration 
of a 3-year period of duty or prior to the completion of required tour of duty at 
a distant station, as noted above, it follows that the directives contained in para- 
graph 453(c) (1) and (2), Manual of the Medical Department, are in contravention 
of and are rendered inoperative by the quoted provisions of the act of 7 Septem- 
ber 1944. 

3. Accordingly, the Manual of the Medical Department is hereby modified as 
follows: 

At end of paragraph 453(a) change period to a semicolon and add: 
"(5) from last station to home in connection with relief from active duty 
or resignation or discharge not the result of her own misconduct." 
Strike out present paragraph 453(c) and substitute: 

"(c) Orders to proceed home will not be given to a nurse who is discharged 
for insubordination or other misconduct, subject to the provisions noted in 
paragraph 454(c)." 

In paragraph 454(b) strike out the second and third undesignated subpara- 
graphs following the form for endorsement on letter of appointment. 

--BuMed. Ross T. Mclntire. 

****** 



- 31 - 



R . ARM . H , W . SM 1 TH , MC . US M . RET . 

BUREAU OF MEDICINE AND SURGERY. 
NAVY lit. PAHTME NT ■ 
*ASHIN(}TON« D.C 

BLDQ 3, ROOM 1 X 



1 

_ -■